What is the initial management for a patient with intermittent pulsatile tinnitus?

Initial Management of Intermittent Pulsatile Tinnitus

For patients with intermittent pulsatile tinnitus, the initial management should include a targeted history and physical examination followed by appropriate vascular imaging, preferably CT angiography or MR angiography, as pulsatile tinnitus often indicates an underlying vascular abnormality that requires prompt evaluation. 1

Initial Evaluation

History and Physical Examination

• Obtain detailed characteristics of the tinnitus:
  • Duration and frequency of episodes
  • Unilateral vs. bilateral presentation
  • Associated symptoms (hearing loss, vertigo, headache)
  • Exacerbating or alleviating factors
• Perform thorough otoscopic examination to:
  • Visualize ear canals and tympanic membranes
  • Look for visible vascular abnormalities (which may be visible on otoscopy)
  • Check for cerumen impaction or middle ear effusion 1
• Conduct head and neck examination including:
  • Auscultation of the ears, neck, and skull for bruits
  • Palpation of the neck and periauricular region
  • Assessment for focal neurological deficits 1, 2

Audiologic Assessment

• A comprehensive audiologic examination is strongly recommended, including:
  • Pure tone audiometry
  • Speech audiometry
  • Tympanometry
  • Acoustic reflex testing 1

Imaging Studies

Imaging is particularly crucial for pulsatile tinnitus, as it often indicates an underlying vascular abnormality that may be serious or even life-threatening 3, 2.

First-line Imaging

• CT angiography (CTA) or MR angiography (MRA) are the recommended initial imaging studies for pulsatile tinnitus 1
• These studies can identify common vascular causes such as:
  • Arteriovenous malformations or fistulas
  • Carotid artery stenosis or dissection
  • Vascular tumors (e.g., glomus tumors)
  • Vascular anomalies at the skull base 4, 2

Additional Imaging Based on Clinical Presentation

• If unilateral tinnitus with asymmetric hearing loss: MRI with contrast of internal auditory canals to rule out acoustic neuroma 1
• If focal neurological findings present: MRI brain with contrast 1
• If initial imaging is negative but clinical suspicion remains high: Consider catheter angiography, particularly if a dural arteriovenous fistula is suspected 4

Important Considerations and Pitfalls

Critical Conditions to Rule Out

• Arteriovenous shunts or malformations
• Carotid artery stenosis or dissection
• Intracranial hypertension (check fundoscopy for papilledema) 5, 6
• Vascular tumors (e.g., glomus tumors) 5

Common Pitfalls to Avoid

• Failing to remove cerumen before assessment
• Overlooking non-otologic causes
• Not performing comprehensive audiologic evaluation
• Ordering unnecessary imaging for non-pulsatile tinnitus 1
• Dismissing pulsatile tinnitus as benign without proper investigation 2, 6

Follow-up Management

• Document resolution, improvement, or worsening of symptoms
• Schedule follow-up within 4-6 weeks to assess response to initial management
• Consider referral to specialized care if:
  • Symptoms persist or worsen
  • Imaging reveals a vascular abnormality requiring intervention
  • Diagnosis remains unclear after initial evaluation 1

Pulsatile tinnitus differs significantly from subjective non-pulsatile tinnitus in its evaluation and management approach. While most cases of non-pulsatile tinnitus may not require imaging, pulsatile tinnitus warrants thorough investigation as it can be a manifestation of serious underlying vascular pathology 3, 2, 6.